APPROACH TO PAIN Sue Celle T.Saavedra, MD, FPCP, FPRA Cagayan de Oro Medical Center

CASE: 46 M with acute left ankle swelling

PAIN  Signal of disease  Most common symptom that brings a patient to a physician’s attention  Different diseases produces characteristic patterns of tissue damage  Quality, time course, and location of a patient's pain complaint and the location of tenderness provide important diagnostic clues

Pain  Unpleasant sensation localized to a part of the body  Described  Penetrating or tissue-destructive process  Stabbing burning, twisting, tearing, squeezing  and/or of a bodily or emotional reaction  Terrifying, nauseating, sickening  Pain of moderate or higher intensity is accompanied by anxiety and the urge to escape or terminate the feeling  Sensation and emotion

 Acute Pain  Associated with behavioral arousal and a stress response  Increased blood pressure, heart rate, pupil diameter, and plasma cortisol levels  Local muscle contraction Limb flexion, abdominal wall rigidity

 Chronic  Difficult to diagnose  Demanding patient  Traditional medical approach of seeking an obscure organic pathology is usually unhelpful  Psychological evaluation and behaviorally based treatment paradigms are frequently helpful  Depression is the most common emotional disturbance or problem

Seven Attributes of a Symptom  Location – radiation  Quality – gnawing, pricking, etc.  Quantity or Severity – Scale of 10  Timing  Setting  Aggravating or Relieving factors  Associated manifestations

 Muskuloskeletal system  Joints, bones, muscles, tendons, ligaments, tissues surrounding the joints  7 attributes  Location  ? Show or localized area of pain  ? Other areas involved  ? Radiation  ? Migratory/Unilateral/Symmetrical

 Quality and Quantity/Severity  ? Character of pain Gnawing, burning, throbbing  Scale 1/10  Timing  ? Onset Acute/subacute/chronic Sudden/insidious/gradual/progressing  Duration  Frequency  Setting in which they occur  ? Activity/Environment/Emotions

 Aggravating or Relieving factors  ? Setting  Associated manifestations  ? Other symptoms  ? ROM  ? Swelling/warmth/tenderness/redness Myalgias Arthritis vs arthralgia  Stiffness Perception of tightness Resistance to movement Timing

APPROACH TO RESPIRATORY SYMPTOMS

Cough  Most common and frequent symptom  Reflex response to a stimuli that irritate receptors in the larynx, trachea or large bronchi  Inflammation of the respiratory mucosa and pressure or tension on the air passages  Indicate the presence of lung disease  Cough per se is not useful for the differential diagnosis

Cough  ? 7 attributes  Setting, Severity, Relieving or Aggravating factors, Associated Symptoms  Presence of sputum often suggests airway disease Asthma, chronic bronchitis, or bronchiectasis  ? Smoking, frequency, acute or chronic  ? Seasonal  ? Productive or dry/hard  ? Phlegm - describe

Dyspnea  Difficulty of breathing/Shortness of breath  Nonpainful but uncomfortable awareness of breathing  Frequently accompanies anxiety  ? Setting  When it occurs? At rest or on exertion?  ? Severity – based on daily activities  ? Aggravated/Relieving factors  ? Associated symptoms

 Determine the time course  Acute  Over a period of hrs to days  Asthma attack  Pulmonary parenchyma involvement Pulmonary edema, pneumonia, pneumothorax, pulmonary embolism  Subacute  Over days to weeks  Exacerbation of pre-existing airways disease  Chronic  Months to years  Indicates chronic obstructive lung/interstitial disease or a cardiac disease

 Orthopnea  Dyspnea that occurs when lying down and improves upon sitting  Quantified - # of pillows  Paroxysmal nocturnal dyspnea  Sudden dyspnea and orthopnea that wakens one from sleep  Usually 1-2 hrs after going to sleep  Tachypnea  Rapid shallow breathing  SOB  Short of breath - dyspnea

Wheezing  Musical respiratory sounds audible to the patient and others  Suggests partial airway obstruction  ? Setting  ? Severity  ? Aggravated & Relieving factors  ? Associated symptoms  Cough

Hemoptysis  Coughing or spitting up of blood  Blood-streaked or pure blood  Originate from disease of the airways, the pulmonary parenchyma, or the vasculature  ? 1 st time or has Hx before  ? Volume  Differentiated from hematemesis

Pain  Chest pain  Lung tissue – no pain fibers  Due:  Inflammation of adjacent parietal pleura  Muscle strain  Cardiac problems – pericarditis  Accentuated by respiratory motion (pleuritic)  ? Radiation  ? Associated Sx: Exertion  MC  Adults – Costochondritis  Children – Anxiety

APPROACH TO COMMON GIT SIGNS AND SYMPTOMS

GIT  Esophagus  Abdomen  Liver  Pancreas  Small and large intestines

Dysphagia  Difficulty in swallowing, the sense that food or liquid is sticking, hesitating, or “won’t go down right”  Sensation of a lump in the throat or in the retrosternal area  Difficulty in transferring food from mouth to the esophagus

 Show where the dysphagia is felt  Chest – esophageal disorder  Throat  Timing  ? Start, intermittent or persistent, progressing  Precipitating factors  Liquid or solid food  Solid – mechanical narrowing of the esophagus  Both – esophageal motility  Associated symptoms  Pain - Odynophagia

Odynophagia  Pain on swallowing  Sharp burning pain suggests mucosal inflammation  Squeezing cramping pain suggests a muscular cause

Indigestion  Distress associated with eating  Heartburn  Excessive gas  Abdominal fullness  Abdominal pain  Nausea and vomiting, etc.

Heartburn  Sense of burning or warmth that is felt retrosternally and may radiate from the epigastrium to the neck  Originates in the esophagus  Reflux of gastric acid into the esophagus  Precipitated by a heavy meal, lying down or bending forward  Suggests reflux esophagitis

Excessive gas  Frequent belching, abdominal bloating or distention or flatus  Normal: 600 ml of gas per day Abdominal fullness  Inability to eat a full meal

Abdominal pain  Mechanisms 1. Visceral pain Hollow abdominal organs contraction or distension or stretched Poorly localized Near the midline Gnawing, burning, cramping or aching Assocd with sweating, pallor, nausea, vomiting and restlessness

2.Parietal pain Inflammation of the parietal peritoneum Steady, aching pain, more severe than visceral pain Localized over the involved structure Aggravated by movement or coughing Relieved by lying still Acute appendicitis

3.Referred pain Pain at distant sites that are innervated at approximately the same spinal levels Often as initial pain becoming intense and seems to radiate from the initial site Well localized, superficially or deeply

 ? Show or localized the pain  Describe the pain  ? Severity  ? Timing  ? Precipitating/Relieving factors  ? Associated symptoms

 Anorexia  Loss of appetite  Nausea  “feeling sick to my stomach”  Retching  Spasmodic movements of the chest and diaphragm that precedes and ends in vomiting  Vomiting  Forceful expulsion of gastric contents out through the mouth

Regurgitation  Raising of esophageal or gastric contents in the absence of nausea or retching  Occurs when there is narrowing of the esophagus or incompetent esophageal sphincter

Bowel function  Diarrhea  Excessive frequency in the passage of stools that are usually unformed or watery  Constipation  Decrease in the frequency of bowel movements  Obstipation  Complete constipation, with passage of neither stool nor gas  Normal: 3 times a day to twice a week

 Melena  Passage of black and tarry stools  Hematochezia  Passage of red blood in the stools

Jaundice or Icterus  Yellowish discoloration of the skin and eyes  Increased amount of bilirubin, a bile pigment derived chiefly from the breakdown of hemoglobin  Mechanism  Increased production of bilirubin  Decreased uptake of bilirubin by the liver cells  Decreased ability of the liver to conjugate the bilirubin  Decreased excretion of bilirubin into the bile with resulting escape of some bilirubin into the blood

 ? Associated symptoms  Color of stools, urine  Buccal mucosa  Itchiness  Pain  Fever  Anorexia